Reset Form
Print Form
Request for Change, Correction
Change your permit
Iowa Department of Revenue
information online!!
or Cancellation of Tax Permit
Go to:
Return This Form To:
Do you have questions on Iowa taxes?
Registration Services
Iowa Department of Revenue
e-mail: idr@iowa.gov
P.O. Box 10465
1-800-367-3388
Des Moines, IA 50306-0465
(Iowa, Omaha, Rock Island, Moline)
Fax: 515-281-3906
515-281-3114 (Local & out of state)
Legal Name ____________________________________________________
Trade Name ____________________________________________________
Address ________________________________________________________
Indicate by checkmark and permit number those permit records you request to change, correct or cancel.
Sales Tax Permit
No. ___________________________________
Motor Vehicle Fuel Tax Permit
No. ___________________________________
Consumer's Use Tax Permit
No. ___________________________________
Retailer's Use Tax Permit
No. ___________________________________
Household Hazardous Material Permit
No. ___________________________________
Employer Withholding Permit
No. ___________________________________
Other
No. ___________________________________
Checkmark and complete the applicable area(s):
Cancel: Reason: __________________________________ Effective date: ____________________
Reinstate: Reason: _________________________________ Effective date: ____________________
Change business/trade name to: ________________________________________________________
Change mailing address to: ____________________________________________________________
_________________________________________________________________________________
Change location address to: (PO Box Not Allowed) _______________________________________
_________________________________________________________________________________
Add corporate officer name: ___________________________________________________________
Address: _________________________________________ Soc. Sec. No. ____________________
Delete corporate officer name: _____________________ Soc. Sec. No. ____________________
Add partner name: __________________________________________________________________
Address: _________________________________________ Soc. Sec. No. ____________________
Delete partner name: _________________________________ Soc. Sec. No. ____________________
Change of filing frequency (effective the 1st day of the next quarter): __________________________
Other corrections: ___________________________________________________________________
You will also need to complete a new permit application form if you are changing:
• ownership, incorporating
• location address from one Iowa county to another and have a sales tax permit or consumer’s use tax permit
Owner/Officer Signature: _____________________________________________ Date: ________________
Title: _____________________________________________________________
92-033 (8/02/06)